Pakistan needs an equitable investment in the health system and collaborative efforts
Authors: Muhammad Farooq, Muhammad Usman
Journal: The Lancet Global Health (2023)

In this issue of The Lancet Global Health, the Global Burden of Disease (GBD) Study Pakistan Collaborators published a comprehensive report analysing the health trends and burden of disease in Pakistan from 1990 to 2019.1GBD 2019 Pakistan CollaboratorsThe state of health in Pakistan and its provinces and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019.Lancet Glob Health. 2023; 11: e229-e243Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar This study asserts the need to address the burden of infectious disease and restrain rising rates of non-communicable diseases. It points out that Pakistan has improved on most health performance indicators, such as life expectancy and healthy life expectancy; however, gender and regional disparities still exist. For example, in Punjab, the most populated province with 110 million residents, life expectancy has improved by around 9·38% from 1990 to 2019, the most by any province in Pakistan. On the other hand, the Baluchistan province, with a population of 8 million, has the lowest life expectancy (63·4 years), with an improvement of just 3·22% from 1990 to 2019. We stress the need to address these disparities by equitable investment in the health system to achieve universal health coverage (UHC) in the country. A recent effort in this regard has been the announcement of a health card for the entire population of Punjab, after piloting this in the Khyber Pakhtunkhwa province, that covers the treatment cost of around 1 million PKR (around US$5650) for every family.2Farooq M Arshad MI Usman M Towards universal health coverage in Pakistan: challenges ahead.Lancet Reg Health Southeast Asia. 2022; 1100003Google Scholar This card will cover all hospitalisations related to surgical procedures and chronic conditions. The sustainability of this scheme (financial and managerial) must be ensured for its successful implementation.2Farooq M Arshad MI Usman M Towards universal health coverage in Pakistan: challenges ahead.Lancet Reg Health Southeast Asia. 2022; 1100003Google Scholar Although it would be challenging for a low-income country, Pakistan must make efforts to ensure the roll-out of this scheme to the whole country. This is particularly essential after the recent floods that have been the worst in the country's history. The severity of these floods has been particularly catastrophic in the Sindh and Baluchistan provinces where the UHC health card has not been yet initiated. These floods resulted in a high number of diseases, mainly water-borne and vector-borne infections, rendering about 8 million displaced people at risk.3The World BankPakistan: flood damages and economic losses over USD 30 billion and reconstruction needs over USD 16 billion—new assessment.https://www.worldbank.org/en/news/press-release/2022/10/28/pakistan-flood-damages-and-economic-losses-over-usd-30-billion-and-reconstruction-needs-over-usd-16-billion-new-assessmeDate: 2022Date accessed: November 20, 2022Google Scholar The lack of UHC in Sindh and Baluchistan (the least performing provinces in terms of health indicators) and the risk of future climate events will further increase the regional gaps in health performance indicators. Climate change is likely to have played a prominent role in increasing the intensity of rainfall and ultimate floods.4McGrath M Climate change: Pakistan floods ‘likely’ made worse by warming.https://www.bbc.com/news/science-environment-62915648Date: 2022Date accessed: November 24, 2022Google Scholar Similarly, climate change made the odds of record-breaking heatwaves in Pakistan and India earlier this year 100 times more likely.5Rowlatt J Climate change swells odds of record India, Pakistan heatwaves.https://www.bbc.com/news/science-environment-61484697Date: 2022Date accessed: November 24, 2022Google Scholar Pakistan is the eighth most vulnerable country to be affected by climate change despite producing less than 1% of global greenhouse gas emissions.6Ramirez R Dewan A Pakistan emits less than 1% of the world's planet-warming gases. It's now drowning.https://edition.cnn.com/2022/08/30/asia/pakistan-climate-crisis-floods-justice-intl/index.htmlDate: 2022Date accessed: November 24, 2022Google Scholar Indeed, the impacts of climate change are global in scale and call for joint efforts, particularly for communities in low-income countries. The decision made in the 27th Conference of the Parties to the United Nations Framework Convention on Climate Change on Nov 20, 2022, to establish a fund through which high-income countries will help the most vulnerable countries cope with climate disasters, is a historic and heartening step.7UN Climate ActionDelivering for people and the planet.https://www.un.org/en/climatechange/cop27Date accessed: November 24, 2022Google Scholar This fund would compensate the most affected countries for the costs of climate disasters made worse by the pollution discharged by high-income countries; however, the working mechanisms are yet to be determined.8Plumer B Friedman L Bearak M Gross J In a first, rich countries agree to pay for climate damages in poor nations.https://www.nytimes.com/2022/11/19/climate/un-climate-damage-cop27.html#:~:text=the%20main%20story-,In%20a%20First%2C%20Rich%20Countries%20Agree%20to%20Pay%20for%20Climate,about%20how%20it%20would%20workDate: 2022Date accessed: November 24, 2022Google Scholar This GBD study further pointed out air pollution (particulate matter) as the leading risk factor for all-cause mortality in Pakistan, contributing primarily to mortality due to cardiovascular diseases. This is an alarming situation for Pakistan, which has been ranked among the top three most polluted countries in the world based on air quality index in 20219IQAirAir quality in Pakistan.https://www.iqair.com/pakistanDate: 2021Date accessed: November 20, 2022Google Scholar due to rapid urbanisation, industrialisation, deforestation, and, more importantly, poorly implemented regulations. However, air pollution, being a transboundary issue, needs collaborative efforts from Pakistan and neighbouring countries such as China and India. A joint investment should be made to collect reliable air-monitoring data together to better understand and tackle the risks to public health.10Usman M Wakeel A Farooq M India and Pakistan need to collaborate against pollution.Nature. 2017; 552: 334Crossref Scopus (0) Google Scholar These neighbouring countries face many transboundary environmental issues. For example, all 25 most polluted cities in 2021 were from Pakistan, India, and China.11IQAirWorld's most polluted cities (historical data 2017–2021).https://www.iqair.com/world-most-pollucted-citiesDate: 2021Date accessed: November 20, 2022Google Scholar India and Pakistan have also been gripped by the crippling heat waves earlier this year.10Usman M Wakeel A Farooq M India and Pakistan need to collaborate against pollution.Nature. 2017; 552: 334Crossref Scopus (0) Google Scholar This situation highlights that, in addition to national interventions, international collaboration will be required to control air pollution.10Usman M Wakeel A Farooq M India and Pakistan need to collaborate against pollution.Nature. 2017; 552: 334Crossref Scopus (0) Google Scholar Pakistan, of course, has a responsibility for its own future, but there are global factors also in play that need to be addressed. We declare no competing interests. The state of health in Pakistan and its provinces and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019Our study shows that progress has been made on reducing Pakistan's disease burden since 1990, but geographical, age, and sex disparities persist. Equitable investment in the health system, as well as the prioritisation of high-impact policy interventions and programmes, are needed to save lives and improve health outcomes. Pakistan is facing several domestic and foreign challenges—the Taliban's return to power in Afghanistan, political turmoil, catastrophic flooding, the COVID-19 pandemic—that will shape the trajectory of the country's health and development. Full-Text PDF Open Access